Children’s community nursing service provides specialist nursing support for children who have acute (critical) health problems, usually on a short-term basis and usually following discharge from hospital and after request via GP or hospital consultant. 

Children’s community nursing service also provides, as part of a Multidisciplinary team (including physiotherapy, occupational therapists, GPs, Paediatric consultants etc), support to the child/young person and family/carer with long term conditions who have chronic health problems and/or disabilities, who often remain with the service on a long-term basis. 

The service is offered to those children who meet the following criteria:

• Children and young people aged 0 - 18 (19 years for those attending special schools)
• Children and young people who are registered with a Wolverhampton City GP 
• Children and young people attending Green Park and Penn Hall Special Schools

These children are supported in schools and advice provided in homes 8am-6pm, seven days a week. For families who wish to access the service outside these arrangements, specialist agreement via the Continued Care Team for Children services will be required.

Support

Children’s community nursing service support may include clinical interventions given at their home, early years settings, school, or the Gem Centre, such as:

• Wound care dressings
• Injections
• Infusions
• Central line care
• Oncology clinical support
• Tracheostomy care and support
• Complex care clinical interventions and support
• Overnight ventilation support
• Oxygen support service

Children’s community nursing service support may also include, for example,

• Clinical nursing support within Green Park school and Penn Hall school
• Palliative and end of life care and support
• Continence support and product provision
• Enteral feeding equipment and training

For some conditions such as Cystic fibrosis, Diabetes, Asthma or Oncology, there are specific Nurses employed by the Royal Wolverhampton Hospital trust or GPs that we will inform your GP about if we have referred you on to these services.

How to access the service

For children and families who want to access our services, please speak to your Paediatric Community Consultant or your GP.

How to give a compliment or compliant about the service

Contact The Gem Centre directly to access the most appropriate person. 

The Royal Wolverhampton NHS Trust service feedback can be provided by visiting Patient experience team.

Contact

• Telephone: 01902 444700
• Children’s Community Nursing Service, The Gem Centre, Neachells Lane, Wednesfield, Wolverhampton, West Midlands, WV11 3PG
• Visit website

• Paediatric services (up the age of 18 years)
• Adult service (18 years and over)

The service recognises that talking about life limiting illness and planning future care needs is never easy, particularly when it concerns the care of children and young adults. Some of these services cater specifically for children and young adults who are coming to the final stage of their illness and are in the last few weeks of their lives. 

We want to offer the child/young person nursing care and support that allows them to remain at home for as long as they can with their families. Being cared for at home allows young people to participate in family life and remain close to parents and siblings.
This service aims to care and support children, young adults and their families from the Wolverhampton area with a Wolverhampton GP or select neighbouring Integrated Care Board (ICB) who have a life limiting illness and wish to be cared for at home. 

The service is available for:

• Children aged 0-18, the Children's Community Nursing service operates from the Gem Centre and is available from 8.30 am to 5.00 pm Monday to Friday and available on the weekend if assessed as required. All staff have a Children’s Nurse Qualification, and additional training in looking after children with Palliative care support needs. The focus will be on the enhancement of quality of life through this difficult and emotional time.
   
• Young adults aged 16-18, the Children's Community Nursing team operates as above and works jointly with the Adult Community Nursing Service to provide a service.
   
• Young people aged 18 and over, the Adult Community Nursing Service provide a 24/7 service. Young people and their families can also contact a dedicated phone line for urgent concerns.

What we do

Palliative Care offered by the Children’s Community Nursing Service includes:

• Nursing care and support is provided to young people and their families in their own home 
• The identification of a named nurse who will co-ordinate each young person`s care to ensure that all the appropriate services are involved.
• Meeting the specific needs of young people and their families through establishing an open, honest and empathic relationship
• An assessment to determine the physical, social, emotional and spiritual needs of the young person and their family. 
• Advice and information face to face or over the telephone, ensuring young people and their families/carers understand what nursing care is being provided and why it is being provided. 
• Provision of emotional support to help each young person and their family through this very difficult and traumatic time.
• Working as part of a Multidisciplinary team (including physiotherapy, occupational therapists, GPs, Paediatric consultants etc.

End-of-life care at home 

Nursing care and support is provided to young people and their families in their own home. The service provided is an 8.30am -18.00pm service 7 days a week. If you have a personalised budget allowance, you will need to discuss your needs with the service lead and this will be agreed on the level of service we can offer on a case by case basis.

We also provide a 24 hour end-of-life service for the appropriate families. This is with support and collaboration from Acorns at Walsall Acorns Children's Hospice.

We work in collaboration with Compton Care for those children and young people in transition to adult services who are palliative/end-of-life.

How to access the service

For children and families who want to access our services, please speak to your Paediatric Community Consultant or your GP who can refer into the service. Most people accessing these services will already be known to the Paediatric or Adult Community nursing team.

How to give a compliment or compliant about the service

The Royal Wolverhampton NHS Trust service feedback can be provided by visiting Patient experience team.

Where you can find us

• Telephone: 01902 444700
• Children’s Community Nursing Service, The Gem Centre, Neachells Lane, Wednesfield, Wolverhampton, WV11 3PG

Some children and young people (up to their 18th birthday) may have very complex health needs, which may be the result of congenital conditions, long-term or life limiting or life-threatening conditions, disability, or the after-effects of serious illness or injury.  A package of additional health support may therefore be needed, which is known as continuing care.  

These needs may be so complex, that they cannot be met by the services which are routinely available from GP practices, hospitals or in the community commissioned by the Black Country Integrated Care Board (ICB) or NHS England.   

Support

They ensure that all assessments are needs led and involve members of the multi-disciplinary team that support the children and young people. They are able to support with discharge planning and assessment, alongside the coordination and planning of care packages. 

How to access the service

• A referral can be made to the Continuing Care Nurse and this is usually completed by the child’s/young person’s key worker such as their School Nurse, Community Nurse or Social Worker.  
• The process should be completed within 6 weeks of the referral being received; however, flexibility needs to be considered depending on the complexities of individual assessments.  
• If the child or young person meets the referral criteria, then contact is made to the parents or carers of the child/young person to undertake ‘Children and Young People Continuing Care’ assessment.  
• An open and fair assessment of health and care needs, for children or young people will then take place.  The key outcome for families is to provide a holistic, fair and thorough assessment of the child/young person’s needs in order to assess whether they require extra support to help meet the complexities of their needs. This means that the child/young person has needs that cannot be met solely by existing universal services such as their G.P or services provided by specialist teams like community nurses.  
• The outcome of the assessment is to determine whether or not individual needs meet the eligibility criteria for continuing care funding using the Children’s Continuing Care framework set out by the Department of Health.  

If the child/young person meets the criteria for continuing care the family are notified of the decision and the continuing care nurse/co-ordinator begins to look at a suitable package of care taking into account, the child/young person and family’s needs.

How are continuing care plans managed alongside the EHC plan

The Education Health and Care Plan (EHCP) process is a coordinated assessment of a child or young person’s needs, based on multi-professional input and focussed on the outcomes which make the most difference to the child or young person and their family. 

Therefore they intend to align the Children and Young Peoples Continuing care process with the EHCP processes where possible. The joint assessment will ensure outcomes are established across education, health and social care that the views, interests and aspirations of the child or young person and their family are documented and that collaborative joint working leads to good practice.

The package of care is then delivered to the child/young person and a review takes place after 3 months, then yearly. A review will also be required if the child/young person’s needs change significantly before this time.

Transition to Continuing Healthcare (18 years plus)

If your child/young person receives child and young person’s continuing care and it seems likely they may need similar support when they reach 18, this should be identified and discussed with parents/carers when they reach the age of 14 years initially. At the age of 16-17 the young person should be referred to the adult NHS continuing healthcare team for assessment. This is a multidisciplinary assessment and a decision regarding eligibility should be made when they reach 17 years old.

How are continuing care plans funded?

The funding for a care package is either provided solely by health or depending on the outcome of decisions at the panel there may be elements of social or educational funding discussed to supplement the package. Personal health budgets are used to deliver an agreed package of care and are personalised to the child/young person’s/family/carers needs.

How to give a compliment or compliant about the service

The Black Country ICB service feedback can be provided by visiting Customer services - Time 2 Talk - Black Country ICB.

Where you can find us

Find out more about children and young people’s continuing care by visiting Continuing Healthcare Black Country ICB and reading the National Framework for Children and Young People’s Continuing Care.

Some people with long term complex health needs are eligible for care arranged and funded by the NHS, which is known as continuing healthcare. Continuing healthcare is a package of care which is arranged and funded solely by the NHS for individuals outside of hospital who have significant health care needs, rather than social or personal needs.  

NHS continuing healthcare can be received in your own home or in a care home.  NHS continuing healthcare is provided free unlike support provided by local authorities which is means tested.

Support

We assess patients who have been identified as likely to be eligible for continuing healthcare. We ensure that patients have a smooth journey through the assessment and commissioning of care process, ensuring decisions are made and communicated effectively. 

How to access the service 

Anyone over the age of 18 who has been assessed as having a certain level of care needs may be entitled to NHS continuing healthcare.  It is not dependent on a particular disease, diagnosis, or condition, nor on who provides the care or where that care is provided.  

If your overall assessment of care needs show that you have a 'primary health need', you should be eligible for NHS continuing healthcare.  Once eligible for NHS continuing healthcare, your care will be funded by the NHS.  This is, however, subject to regular reviews and should your care needs change, the funding arrangements may also change.  It is not a lifelong eligibility.

Assessment

The initial assessment will be a Checklist, but this will not indicate eligibility, just a need for a further, in-depth assessment.  A nurse, doctor, other qualified healthcare professional or social care professional can complete the Checklist to refer individuals for a full assessment of eligibility for NHS continuing healthcare from either a community or hospital (Checklist should not be completed until the individual's needs on discharge are clear) setting.

How to give a compliment or compliant about the service

The Black Country ICB service feedback can be provided by visiting Customer services - Time 2 Talk - Black Country ICB.

Find out more about NHS Continuing Healthcare and read the National framework for NHS continuing healthcare and NHS-funded nursing care.